Common mental disorders and associated factors among mothers of children attending severe acute malnutrition treatment in Gedio Zone, Southern Ethiopia, 2022: a cross-sectional study

Background Common mental disorders describe the physical, mental, and social disturbances that are more prevalent in low and middle-income countries. Mothers are among the more vulnerable groups especially mothers having children with under-nutrition. However, there are limited studies about the magnitude of common mental disorders among mothers of undernourished children in Ethiopia. Therefore, we aimed to assess the magnitude of common mental disorders and associated factors among mothers of children attending severe acute malnutrition treatment in Gedio Zone, Southern Ethiopia. Methods A cross-sectional study was employed on 405 systematically selected participants. The outcome variable was assessed by a self-reporting questionnaire (SRQ-20) which was applicable and validated in Ethiopia. Data were entered and analyzed by EPi data version 5 software and SPSS version 25 respectively. Model fitness was checked by Hosmer Lemeshow’s test. Logistic regression was employed to identify significant determinants. A p-value < 0.05 was used to declare association and expressed by odds ratio with a 95% CI. Result In this study, the magnitude of common mental disorders was 33.16% (95% CI [28.5–38])). In multivariable analysis, six factors poor social support [AOR: 14.0, 95% CI (5.45, 35.9)], educational status [AOR: 1.95, 95% CI (1.07. 3.55)], cigarette smoking [AOR: 10.9, 95% CI (1.78, 67.01)], mother of a child with another chronic disease [AOR: 3.19, 95% CI (1.13, 8.99)], sexual violence [AOR: 4.14, 95% CI (1.38, 12.4)] and mothers with chronic disease [AOR: 3.44, 95% CI (1.72, 6.86)] were significantly associated with common mental disorders. Conclusion The magnitude of common mental disorders was high. Six factors were significantly associated with common mental disorders; social support, sexual violence, maternal chronic illness, educational status, smoking, and mother of child with other chronic disease. Community awareness regarding the effect of violence, substance use, and social support on mental health should be created by the local stakeholders.


Introduction
Common mental disorder (CMD) is a gross name for physical, mental, and social disturbances used to describe a range of symptoms like depression, anxiety, or somatic manifestations [1].It has adverse economic, social and psychological consequences for the individuals, their children, their families and the community [2].
Globally, 4.4% of mothers of malnourished children had CMD.Studies from different countries showed that the prevalence of CMD among mothers having children with under-nutrition is higher than mothers of children with normal nutritional.For instance, in Uganda and Kenya among mothers of malnourished children 42% and 64.1% had common mental disorder [3,4].Moreover, in Nigeria 40.7% of mothers of malnourished children had CMD [5].
A disproportionate number of common mental disorders (CMDs) are experienced by mothers of malnourished children in poor nations [6], 30-40% of this population are reported to have CMDs, according to studies, which is much greater than the 10-17.6%prevalence seen in the overall population [7][8][9][10].
Poor maternal mental health can adversely affect the nutrition, health, and psychological well-being of the child [4].It also increases the risk of growth failure [11,12].CMD can disrupt the mothers' ability to cope with the demands of childcare [13][14][15].Reduction in the burden of CMD leads to a reduction in child growth retardation by 30%.Therefore, by doing this, it is possible to decrease both maternal and under-five mortality [16].
Mothers of malnourished children are more likely to experience common mental disorders due to a number of factors, such as poverty, food insecurity, educational attainment, stigma, lack of social support, mother's nutritional status, quality of care, and limited access to healthcare.Moreover, the emotional strain of witnessing a child's suffering from malnutrition can significantly contribute to the development of mental health issues in mothers [5,[17][18][19].
In 2014, 56% of under-five mortality was related to the exacerbating effects of malnutrition [20] and still now the mortality is high.Even though maternal CMD and SAM among children being strongly related and having a bidirectional relationship, maternal mental health is largely neglected in developing countries [21].Furthermore, the magnitude and effect of maternal mental disorder on children nutritional status is unknown [22].
In Ethiopia, little is known about the magnitude of CMD among mothers' of malnourished children.
Therefore, we aimed to assess the magnitude of common mental disorders and associated factors among mothers of children attending SAM treatment in Gedio Zone, Southern Ethiopia, 2022.

Study area and period
Our study was conducted in Gedeo zone public health centers.Gedeo zone is found in the South Nation Nationalities and People Region (SNNPR), and the capital city is Dilla, 394 Km away from Addis Ababa, which is the capital city of Ethiopia and 84 km away from Hawassa.The altitude of Dilla is 1765 m above sea level.Gedeo zone has a total population of 847,434; of whom 424,472 are males and 422,696 are female.Only 12.72% of the population lives in the urban areas.In this zone, the average household size of the family is 5.1.The livelihood of the population is also depending on agriculture and livestock production.Gedeo zone has a total of seven woredas and two administrative towns [23].Our study was conducted in 3 woredas (Yirgachefe, Wonago and Bule) and one administrative town (Yirgachefe).
The medical facilities provide promotional, curative, rehabilitative, and preventative therapies to the local population.Women who are going through the postpartum period, giving birth, and attending prenatal checkups are frequently given health education by the health clinics.But they didn't give attention to maternal mental health of SAM children.The study was conducted from March 1, 2022 to April 30, 2022.

Study design
Institution-based cross-sectional study design was employed on mothers of children (6-59 months) who are attending SAM treatment at an outpatient program.

Source population
All mothers of children (6-59 months) who are attending SAM treatment at an outpatient programs in Gedio Zone.

Study population
All mothers of children (6-59 months) who are attending SAM treatment at an outpatient program in the selected areas (Yirgachefe, Wonago, and Bule Woredas, and Yirgachefe town).mother of child with other chronic disease.Community awareness regarding the effect of violence, substance use, and social support on mental health should be created by the local stakeholders.

Eligibility criteria Inclusion criteria
All mothers-to-child (6-59 months) pairs who are attending SAM treatment at outpatient program in Gedio Zone were included.

Sample size determination and sampling technique02
A single population proportion formula was used to calculate the sample size by considering the following statistical assumptions; P: proportion of maternal CMD in children attending health facilities in Nigeria which was 40.7% [5], Z α/2 : the corresponding Z score of 95% CI, d: Margin of error (5%) and N: Sample size.

Sampling procedure
Gedeo zone has a total of seven woredas and two administrative towns.In those woredas and administrative towns, there are 18 health centers.Our study was conducted in 3 woredas (Yirgachefe, Bule, and Wonago) and one administrative town (Yirgachefe) which was selected using lottery method.From Yirgachefe, Bule, Wonago woredas and Yirgachefe town 4, 2, 3, & 1 health centers were selected respectively.The sample size was proportionally allocated to the selected health centers based on patient follow.The medical record number of the children was used as a sampling frame.A systematic random sampling method was used to select each participant by using a K value of 3 (Fig. 1).

Data collection tool and procedure
Data were collected using interviewer administeredstructured questionnaire, which was adopted from previous studies and then adapted to the local contexts.The questionnaire includes information about socio-demographic, maternal and childhood-related characteristics.
The SRQ-20 was used to assess the dependent variable which was developed by the World Health Organization (WHO) as a screening tool.The tool was validated in multiple developing countries' settings and has good sensitivity and specificity.It was a scale-based score consisting of 20 yes or no questions which ask about multiple symptoms which have occurred within the preceding 30 days.When a symptom was present within the specified period, the individual was given a score of 1, while 0 represents the absence of symptoms within the same period.The sum of all the scores represents the overall SRQ-20 score and higher scores represent poorer maternal mental health.We considered a cut-off maternal SRQ score of ≥ 8 to define maternal CMD which was based on previously published works [24].Moreover, the Oslo Social Support scale was used to assess social support.
Ten BSc nurses who can speak Gede-uffa and Amharic were considered as data collectors.Along with them, two supervisors were involved during data collection time to supervise the overall data collection procedures.After signing a consent form, each participant was interviewed face-to-face.

Operational definitions
Maternal CMD is defined as those mothers who score ≥ 8 on SRQ scale [24].
Poor social support expressed as those mothers scored 3-8 from the total sum score of 14 on Oslo Social Support scale [25].
Current substance use described as mother who uses (non-medical use only) at least anyone of substance (alcohol, chat, or cigarette) currently or for the past three months [26].
Past and current medical illness used to describe those mothers who have known chronic medical illness and their diagnosis confirmed in any health institution and currently have follow-up.

Data quality assurance
The questionnaire was first developed in English version then translated in to Gede-uffa and Amharic languages.To ensure its consistency, it was translated back into English.The interview was conducted using a Gede-uffa version questionnaire.Two days of training were given to data collectors and supervisors; about the purpose, study tool and overall data collection procedure to be eminently maintained by them during data collection time.Pre-test was conducted on 5% of the study participants.

Data analysis
The data were checked for completeness and consistency.It was entered and analyzed by EPi data version 5 software and SPSS version 25 respectively.Descriptive statistics were used to explain the study participant's data.The model fitness was checked by Hosmer Lemeshow's test.Bivariate and multivariable logistic regression analysis was conducted to identify the associated factors.Those variables with a p-value < 0.25 on bivariate analysis were selected for multiple logistic regression.A P-value less than 0.05 were considered statistically significant and an association was expressed by odds ratio with a 95% Confidence interval.

Result
Among the total of 405 participants, only 389 were eligible with a response rate of 96.04%.

Maternal related characteristics
Two hundred forty-five (63%) mothers were aged ≥ 18 years at marriage.Twenty (5.1%) of mothers had a history of sexual violence and 63 (16.2%) had chronic diseases.Seventy-five (19.3%) of participants took alcohol.Three hundred sixty-eight (94.6) of them had no physical violence.Two hundred ninety-two mothers (75.1%) had poor social support (Table 2).

Children related characteristics
In this study, the median birth order was 3 (IQR: 2, 4).Two hundred fifty-one (64.5%) of mothers' children aged less than 5 years and 221 (56.8%) were male.More than half (51.9%) of children were fully immunized.Only twenty-eight (7.2%) of mothers' children had a chronic disease.Two hundred forty (61.7) of mothers gave birth at health facilities and 77 (19.8%) of mothers' children had a previous history of malnutrition (Table 3).

Magnitude of common mental disorders
In the present study, the magnitude of CMD among mothers of children on SAM treatment was 33.16% (95% CI [28.5-38]) (Fig. 2).

Factors associated with common mental disorders
In the current study, logistic regression was employed.Model fitness was assessed by Hosmer and Lemeshow's Test (p: 0.53).In bivariate analysis, only 11 variables had a p-value < 0.25 which were eligible for multivariable logistic regression.However, only six variables remained significantly associated with common mental disorders (social support, sexual violence, maternal chronic disorder, educational status, smoking, and children with another chronic disease) in multivariable logistic regression (Table 4).
In this study, mothers of children with chronic disease had 3.2 times [AOR: 3.19, 95% CI (1.13, 8.99)] more risk of having CMD as compared to their opposite group.Moreover, mothers who had a history of sexual violence had 4 [AOR: 4.14, 95% CI (1.38, 12.4)] times more odds of CMD.Lastly, mothers with chronic disease had a 3.4 [AOR: 3.44, 95%CI (1.72, 6.86)] times higher burden to develop CMD in contrast to their counterparts (Table 4).

Discussion
This study aimed to assess the magnitude of common mental disorders and associated factors among mothers of children attending SAM treatment in Gedio Zone, Southern Ethiopia.In this study, the magnitude of CMD was 33.16% (95% CI [28.5-38])) which was similar to a study done in Ethiopia (36.6%) [27].It might be because of similar assessment tool was used to assess the dependent variable.However, it was high in contrast to another study conducted in Ethiopia among the general population (21.58%) [28].This might be due to our study being conducted on the most vulnerable groups (mothers of SAM children).
Our finding was low as compared to studies conducted in Nigeria (40.7%) [5], Mali (71%) [17], Uganda (42%) [29] and Sudan 41.5% [30].It might be due to that the previous studies were conducted with a small sample size and conducted on both programs but in our study, we considered only children on OTP.Furthermore, it might be because of socio-cultural differences.
Even though the problem is high in Africa, our finding is similar to studies done in Vietnam (31%) [31] and Brazil (34%) [32].This similarity might be due to the above studies were also conducted in rural community in which maternal mental service is low.Our finding is high as compared to the global prevalence (17.6%) [33].This might be due to socio-cultural and economic variation.Mothers who had poor social support had a higher risk of developing CMD.This finding was supported by studies done in Ethiopia [27] and Brazil [34].Women with poor social support might have feelings of neglect by others which lead to social isolation and emotional disturbances.
Illiterate mothers had more odds of CMD.This study was similar to studies conducted in Ethiopia [35], Tanzania [36] and Chile [37].This similarity might be because education helps to improve cognitive ability.Moreover, higher education can enhance social capital, ultimately decreasing feelings of insecurity and vulnerability.
Mothers who smoke cigarettes have a higher risk of CMD as compared to nonsmokers.This study was similar to studies done in India [38] and Tanzania [39].This similarity might be due to nicotine leading to poor concentration, low mood, and stress.Furthermore, smoking can increase the level of psychological distress and complicate or exacerbate mental illness and its treatment.
Mothers with chronic disease had more odds of CMD in contrast to their counterparts.This might be due to bidirectional relationship between chronic disease and common mental disorders and also due to those who are living with chronic illness having limited daily activities.As a result, they experience dissatisfaction in life which exposes them to emotional strains and ultimately to depression and anxiety.
Mothers of children with chronic diseases were more likely to have CMD.This might be due to the occurrence of additional chronic diseases on SAM children creating a high level of stress on mothers and making the level of mental illness double.Lastly, mothers who had a history of sexual violence had higher odds of CMD.This finding is supported by a study done in India [38].This could be due to sexual violence triggering feelings of helplessness, low selfesteem and depression and increasing the risk for mental disorders.
Generally, this study showed pertinent issues to overcome the problem.It will help clinicians and concerned bodies to address common mental disorders among mothers' of malnourished children by recognizing the identified factors and putting focused intervention strategies towards the identified factors.Furthermore, it helps policy makers and program designers.However, our study didn't show a causal relationship between the dependent and independent variables.Moreover, during sample size determination design effect were not considered.

Conclusion
In this study, the magnitude of CMD was high.Six factors were significantly associated with common mental disorders social support, sexual violence, maternal chronic illness, educational status, smoking, and mother of a child with another chronic disease.The Federal Ministry of Education should incorporate maternal mental health assessment on severe acute malnutrition management guidelines.Community awareness regarding the effect of violence, substance use and social support on mental health also should be created by the local stakeholders.Furthermore, it is better to provide attention to mothers with chronic diseases and mothers of children with chronic illnesses.

Fig. 1
Fig. 1 Schematic presentation of sampling procedure

Fig. 2
Fig. 2 Magnitude of common mental disorders among mothers of children attending severe acute malnutrition treatment in Gedio zone, Southern Ethiopia, 2022 (n = 389)

Table 1
Maternal and child socio-demographic variables of common mental disorders in Gedio zone; 2022 (N = 389)

Table 2
Maternal health status related variables of common mental disorders in Gedio zone; 2022 (N = 389)

Table 3
Children related variables who attend severe acute malnutrition treatment in Gedio zone, Southern Ethiopia, 2022 (N = 389)